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Does Going to a Psychotherapist Mean You’re Mentally Ill?

Does going to a psychotherapist mean you’re mentally ill? If you want it paid for by your health insurance, then the answer is yes. Why? Because in order to get paid, your therapist is required to diagnose you with a mental disorder. Another way to think about this is that insurance companies cover health problems. From their perspective, if they are going to pay your therapist, she better be providing medical services that fix something wrong with you. If you’re simply there to shoot the breeze about your feelings, they aren’t obliged to pay.

This places your therapist in an awkward position. She wants to help you. At the same time, she also wants to get paid because, well, even helpers have to eat. The easiest way for her to get paid to talk to you about your troubled marriage, dictatorial boss, aging parents, or overscheduled kids is by billing your insurance company. And so, she must convert your problems into disorders because insurance companies are in the business of paying doctors to treat medical conditions, not talk to people.

Thus, life’s problems are transformed into an ever-expanding list of mental disorders. Human feelings and conflicts are recast as diseases. For every problem presented, a corresponding diagnostic category has been invented:

Trouble with math, reading, or writing? Mathematics Disorder, Reading Disorder, or Disorder of Written Expression.

Drama Queen: Histrionic Personality Disorder

Self-absorbed and grandiose: Narcissistic Personality Disorder.

The list goes on and on and it gets longer every time the American Psychiatric Association revises its diagnostic manual. Potential future diagnoses:

Temperamental kid: Disruptive Mood Dysregulation Disorder

Forgetful as you get older: Mild Neurocognitive Disorder

Using the Internet too much: Internet Addiction Disorder

None of this is meant to trivialize the concerns people bring to psychotherapy. As anyone with a temperamental kid or a spouse who uses the Internet too much can attest, these can be debilitating problems worthy of professional attention. But this doesn’t make them diseases. Most of us intuitively know this, despite being told otherwise by well-meaning but conceptually confused mental health professionals. The conceptual confusion at the heart of the matter arises from considering psychotherapy a form of medical treatment to begin with. Doing so constitutes a category mistake, according to psychotherapists Jay Efran and José Soler-Baillo:

This category mistake situated the therapist’s activities in an inappropriate conceptual envelope. Therapists do not treat symptoms or cure diseases. They have no salves to apply, no antibiotics to prescribe, and no surgical instruments to wield. The association with the medical model and disease-entity approach continues to seduce us into analyzing our craft using conceptual tools that are not well suited to the task. As even Freud acknowledged, psychotherapy is not a medical treatment—it is merely a form of dialogue or conversation. (Efran & Soler-Baillo, 2008, pp. 88-89)

This means that helping someone decide whether to remain in a marriage, change careers, confront an abuser, or forgive a parent aren’t akin to fighting an infection, removing a tumor, setting a broken limb, or stitching a wound. This doesn’t make these less important activities. It just makes them qualitatively different from medical interventions.

From a practical standpoint, this creates difficulty because even though we can see how helping someone come to terms with his sexuality is different from curing his genital warts, we still appreciate the benefits of each activity and want our health insurance to cover both. This perhaps explains why so many people remain invested in keeping psychotherapy under the medical umbrella. Otherwise insurers might stop paying therapists to talk to people about their problems and very few of us want to see that happen. Psychotherapists may not treat anything in the same way as medical doctors, but the conversations they have really do help people. Consequently, clients and therapists wind up speaking two different languages: the medical lingo they use with insurance companies and the everyday talk they engage in with each other.

Speaking these two different languages may be an imperfect solution, but many contend that for practical reasons we have no other choice. We need to use the language of disorder and treatment with insurers so that they will pay for services, or so the argument goes. We just mustn’t take what we tell them too seriously. Yet continuing to pretend for insurance purposes that psychotherapy is a medical treatment doesn’t correct the original category mistake that got us into this conceptual morass in the first place. It also fails to heed psychiatrist R. D. Laing, who warned that “it is a form of self-deception to suppose that one can say one thing and think another” (1965, p. 18).

Going to psychotherapy doesn’t mean you’re mentally ill—unless we all continue to talk about it as if it does.

Comments and Discussions

Submitted by David Elkins (not verified) on February 14, 2012 - 4:18pm.

Jon,
Excellent piece! The medical model in psychotherapy is a major problem. Since the 1960s, therapy has gone "viral" and people use therapy for all kinds of life situations that have nothing to do with "mental illness." We continue to play the medical model game, however, because it's the way clinicians get paid these days. Disentangling ourselves from medical model ideology and all its benefits will be very, very difficult -- and it will cost us a lot financially, I suspect. But it's time....

First, when it comes to healthcare, our society is all tangled up in a web of conflicted feelings and conflated thoughts about wellness, illness, and economics . This is true when it comes both to providing and paying for professional services for or health matters generally as well as mental health in particular.

Health care in the US, as a matter of public policy and private insurance, generally tends to privilege treatment of disorder to a minimum level of non-pathology. The system is oriented to doing this rather than investing in care to optimize wellness.

Historically, the so-called “health care system” has been based on a disease treatment or disorder abatement model. While health care and disease treatment are not polarities, they may be orthogonal concepts. And this is where the language employed at-large about such matters borders on deceptive: “Health care” does not accurately represent the intent of the System or most persons’ experience with it. Our society encourages treatment of illness; it pays for services provided to those who are sick. This was the very point made more than a half-century ago by Thomas Szasz who proclaimed the “myth of mental illness” (1960) and decried the obfuscation of the language surrounding so-called illness and treatment (1961).

Confusion over Purpose

Second, many people are confused, for a number of reasons, about these questions: Just what is the proper role of mental health services? And: When or why one should go to a psychotherapist? In what mental state do we seek “help” from a mental health professional?

As Szasz pointed out in 1960, what some pathologize as mental illness may well be described simply as one struggling through life’s arduous challenges.

This raises the language issue. If psychotherapists don’t use the terminology of pathology, they need alternatives for:

Treatment –– which implies application of the medical model: working to fix or repair a deficiency.

Therapy –– which means to heal, as does chiatry in psychiatry –> If I am not sick, do I need to heal?

Intervention –– which implies force behind the delivery of the assistance.

Alternative to Psychotherapy

If you look around, there is an industry –– not a profession! –– that has grown up around providing quasi-therapeutic, quasi-counseling services without the stigma of psychotherapy’s pathology. The so-called “coaching” industry has given rise to all manner of specialties that conceivably might otherwise find expression in a psychotherapist’s counseling office:

Relationship coaching

ADD / ADHD coaching

Grief coaching (I’m not making this up)

Science?

Moreover, the blame for the confusion on the part of the public which is uncertain about when to seek the assistance of a psychotherapist falls squarely at the feet of the profession of psychology. It has loudly proclaimed to be a positivistic science for more than half a century, and yet it cannot agree within itself as to modalities, standards, and bases of the care it would provide.

Yes, as a society we need to move beyond illness and stigma in psychotherapy. Both the psychological profession and society at-large need better clarity about what psychotherapists can do for those who would or should seek help for non-organic challenges with life.

Perhaps as a modest first step, psychotherapists could deploy better language to describe what someone receiving psychotherapeutic services in today’s world can expect.

Mortality

Death is the great certainty of life -- and a subject we almost never talk about. How we live in its shadow, and the choices we make about the best way to live a life where time is the only non-renewable resource, is a key element of existential thought.